Appeals & Grievances Nurse

General Information

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Work Location: Los Angeles, USA Onsite or Remote Flexible Hybrid Work Schedule Monday-Friday, 8:00am-5:00pm PST Posted Date 10/30/2024 Salary Range: $61.79 - 79.91 Hourly Employment Type 2 - Staff: Career Duration Indefinite Job # 20137

Primary Duties and Responsibilities

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As the Appeals & Grievances Nurse, you will play a key role in managing and resolving New Century Health Plan member appeals and grievances. You will:

• Ensuring timely, accurate, and thorough review of member and provider complaints, working closely with clinical and administrative teams.
• Assessing cases to determine the appropriateness of medical care and services rendered in relation to Medicare guidelines, compliance requirements, and internal policies.
• Identifying and investigating Potential Quality Issues (PQIs) to ensure continuous improvement in care delivery.
• Complete other duties as assigned. 

Salary Range: $61.79-$79.91/hourly

Job Qualifications

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We’re seeking a highly qualified candidate with:

• A BSN or MSN degree, required

• Current valid California RN license, required

• Minimum of 2 years’ experience in a managed care or Medicare Advantage setting is highly desired

• Experience in handling appeals, grievances, utilization management, or potential quality issues.

• Knowledge of Medicare Advantage plan operations and CMS regulations, highly desired

• Strong clinical assessment and decision-making skills, particularly in evaluating medical necessity

• Thorough understanding of Medicare Advantage regulations, especially related to appeals, grievances, and PQIs, highly desired

• Excellent written and verbal communication skills to communicate complex medical information to members and providers effectively

• Proficiency in Microsoft Office Suite and case management software